Special Surgical Procedures II
LESSON 2: Procedures in Gynecological and Obstetrical Surgery
Section Ii:
2-18
2-18. OPERATIONS FOR URINARY STRESS INCONTINENCE
a. General.
(1) This operation involves the repair of the fascial supports and pubococcygeal muscle surrounding the urethra and the bladder neck. It is done through either a vaginal or an abdominal approach.
(2) Normal micturition (urination) depends on a finely coordinated group of voluntary and involuntary movements. As a result of volitional impulses, voiding may be inhibited or stopped by contraction of the perineal and periurethral musculofascial structures.
(3) The type of operation selected depends on the severity of stress incontinence, the extent of the lesion causing it, the patient's ability to use the anatomical mechanism for voluntary inhibition of urination, and the operations that have already been performed for correcting it. Stages of stress incontinence are classified in relation to frequency and degree of incontinence, the presence of other diseases, and the function of the pubococcygeus muscle (levator ani).
(4) The aim of any operation for urinary stress incontinence is to improve the performance of a dislodged or exhausted bladder neck. The surgeon endeavors to restore or reconstruct the supporting structures, the operation thereby resulting in the effective closure of the bladder neck.
(5) Previous pelvic operations may have resulted in scarring and distortion, with displacement of the bladder neck to an unfavorable position for proper functioning. Conditions such as uterine prolapse, cystocele, urethrocele, cystourethrocele, or urogenital fistulas following therapy may be associated with stress incontinence.
b. Operative Procedure--Vaginal Approach.
(1) A Foley catheter is passed into the bladder. The posterior vaginal wall is retracted, and an incision is made through the anterior vaginal wall down to the urethra and bladder.
(2) The vaginal wall is dissected from the bladder and urethra; the neck of the bladder is sutured together with fine chromic gut. The wound is closed, as described for vaginal repair.
c. Operative Procedure--Vesi-courethral Suspension (Marshall--Marchetti Procedure).
(1) Through a suprapubic abdominal incision, the space of Retzius is entered, and the bladder and urethra are freed from the surrounding structures.
(2) Mattress chromic gut sutures number1 or Mersilene number 0 are inserted through the supporting fascia of the vaginal wall on either side of the urethra and bladder neck; they are
then passed through the muscle associated with the symphysis pubis, thereby providing support to the urethra and bladder neck.
(3) Additional sutures are introduced in the lower and lateral portions of the bladder wall and are attached to the posterior portion of the rectus muscles, thereby pulling the bladder anteriorly to obliterate the space of Retzius.
(4) The wound is closed and may be drained with a Penrose drain.
